Many doctors are turning down money attached to Medicare's long-sought chronic care management code, citing the cost of setting up systems to meet its "onerous" requirements. From MedPage Today.
Now, physicians can be paid for the hours of non-face-to-face time they spend on behalf of beneficiaries with two or more chronic conditions -- care many doctors have provided for free -- if they document at least 20 minutes per month reviewing a patient's issues and answering questions.
Looking a Gift Horse in the Mouth?
But in a surprising twist, many doctors across the country are turning down the money attached to 99490, saying the time and cost of setting up systems to meet the code's "onerous" requirements make it not worth the relatively small amount Medicare pays.
Other physicians who successfully implemented CCM services, praising the payment as "a game changer," nonetheless cautioned that in retrospect it was a challenge to get their systems in compliance, and said they've seen the workload turn many of their colleagues off.
"It's a great idea Medicare ended up making frustrating for doctors," said Joseph Scherger, MD, vice president for primary care at Eisenhower Medical Center, a 48-physician practice in Rancho Mirage, Calif. "They screwed this one up, in my opinion, by requiring a signed contract and 20% co-payment from the patient," he said.
"Now, patients may ask, 'Doc, why do I have to start paying this $8 a month fee for you to do work that I've always assumed you did anyway? Now, I have to start paying you to get richer on my behalf? You're just trying to go after more money from Medicare.' It's a tremendous disincentive."
"Medicare did put a lot of money behind it, and the upside for practices doing a lot of care coordination could be really great," Scherger said. But to patients, "this thing smells fishy."
Brenda Vozza-Zeid, MD, an internist in Henderson, Texas, said she is disappointed. "I was really looking forward to it," she said. But when she looked at what she'd have to do to get paid, she found "it was impossible."
That's because to submit claims for 99490, physicians can't also submit claims for transitional care management, home health, hospice, or certain end-stage renal disease service codes the same month. As a result many of Vozza-Zeid's 4,000 patients who would otherwise be eligible are excluded.
George Abraham, MD, associate chief of medicine at Saint Vincent Hospital in Worcester, Mass., and governor of the state's chapter of the American College of Physicians, has submitted 99490 claims for some of his eligible patients "because we'll take peanuts." But he too has concluded "it's not worth the time."
One of five internists in a San Diego, Calif., practice with thousands of Medicare beneficiaries, Raymond Pigeon, MD, said his group won't bother with the new code. "You have to make sure no other physicians are submitting that CCM code for that patient. Even cardiologists, if they wanted to, could be billing Medicare for that."
Additionally, 99490 requires the practice's EHR "to have a clock on it, to capture the exact number of minutes you spent on each person," which Pigeon said his practice's clinical documentation charges a fee to use.
And remember, he said, Medicare only pays 80% of that $42. Paperwork must be generated to bill the beneficiary for the rest, which might sometimes be tough to collect.
"It is complicated," said Robert Wergin, MD, of Milford, Neb., president of the 121,000-member American Academy of Family Physicians, which pushed for Medicare to approve the code.
"One of the hard things is finding a way to explain this to patients. And on the business side, how do you justify the infrastructure you need to be in compliance?" Of family medicine practices surveyed last year, about 28% did not have a certified EHR, he said. The AAFP and other physician groups pushed CMS to adopt the non-face-to-face service code, but as Wergin said "we suggested that Medicare reduce or keep the complexity of making this work to a minimum."
Larger group practices might be better situated to take advantage of the code, but even San Diego's Sharp Rees-Stealy Medical Group, with about 11,000 fee-for-service and 17,000 managed care Medicare beneficiaries, has no physicians now billing 99490, said Sharp family physician Steven Green, MD.
"I was at a recent American Medical Group Association meeting in Las Vegas, and the question came up: Is anyone using this? And everyone in the room but one said 'No.'"
On the Other Hand
Not all physicians are finding the new code unusable; some have overcome obstacles. But even they said there were challenges.
One is Samuel Church, MD, a family physician in rural Hiawassee, Ga., who called the payment "game changing," and "a bigger deal than almost any other payment reform issue we in primary care have encountered."
As of early June, Church had signed up 300 of the 1,300 Medicare beneficiaries in his practice with two or more chronic conditions, with a goal to add the rest. The patients are managed by himself, a registered nurse, and a physician assistant, and he's had no problems convincing them why this is worth their co-payments.
"There's no question that getting patients to pay more is a potential issue," he says. But he explains that doctors need to be paid for extra work they do on behalf of their patients "in the background, and before there was not a mechanism to do that, but now there is. And usually, they say they're thrilled to have that attention paid to their record. They want to be followed more closely."
"I got excited by this because it struck me that I'll now get paid for doing things that I was already doing, or that I should expand on," such as scheduling calls with patients before their regularly scheduled visit to be prepared to address new problems, talking with specialists, and reviewing medications.
After the visit, the team phones the patient to make sure prescriptions are accomplishing their goal to make the patient feel better. "And we scour their charts for other things we can do that might keep them healthy," he said.
The additional money, he said, "has prompted me to have a system where I'm doing this on a more regular basis. You embrace a concept of being somebody's doctor all year long, not just two or four times a year, and that way it makes sense."
Church said that true chronic care management avoids visits for many patients, clearing his schedule so others who need to come in don't have to wait as long. Sometimes, a monthly scheduled call allows the doctor to learn about a patient's worrisome new symptom that might have gone unchecked for months until the next visit, he said.
He cautions, however, that the system wasn't simple to set up. His EHR needed adjustment, and for staff "it was a bit of a culture shift." He wasn't officially ready until April.
Hugh Taylor, MD, a family physician in Hamilton, Mass., has enrolled 160 beneficiaries in the CCM service and said, so far, all is going well, although he's "amazed and dismayed" so many other doctors see too many barriers to get programs started.
"When adult children come in with their elderly parents, they're delighted. They say 'Wow. This is great. Someone else is regularly checking on my mom and dad.'"
Tasks include arranging for a patient to get a hospital bed at home, or other medical equipment like nebulizers or CPAPs, and reviewing notes from specialists, he said.
Taylor, who has about 700 Medicare patients he thinks will qualify, said he "doesn't plan on reaping a fortune" from 99490, but does expect it to pay for itself. "Our plan is to hire someone who would work three-quarters time to start with" to provide services that keep patients conditions "from getting out of control and help keep them out of the hospital" before it's time for their next regular visit.
"But it is trouble, there's no question about that," he said. "It does require extra resources. ... the major thing is counting the minutes to get to 20 each month," a requirement he thinks Medicare should drop. "That's a hassle factor, and they should get rid of it."
Peter Hollmann, MD, a Pawtucket, R.I., internist and member of the American Geriatric Society Board, says that while there are problems with implementing the new code and getting doctors on board, "it's a very positive thing, a fee-for-service attempt to stimulate primary care practices to be more advanced," with more systematic care management practices.
"The question is, will it stimulate that, or will it simply be a way to reward doctors who already did make this investment? I think it will probably do both."